Assessing and Managing Wheezing in Clients with Mouth Burns: A Nurse’s Critical Rol

Nurses play a pivotal role in assessing and managing clients with burn injuries, especially when respiratory complications arise. In this article, we will explore a scenario where a nurse encounters a client with burns inside the mouth who is initially wheezing but later experiences the cessation of wheezing. We will discuss the nurse’s crucial role in addressing this situation and ensuring the client’s well-being.

The Importance of Prompt Assessment

Assessment is a cornerstone of nursing care, and it holds particular significance in the context of burn injuries. Burn injuries can affect various systems in the body, including the respiratory system. When a nurse notes burns inside a client’s mouth accompanied by wheezing, it raises concerns about potential respiratory distress or airway compromise.

The Scenario

Imagine a client who presents with burns inside the mouth and is wheezing during the initial assessment. Wheezing is an audible sound produced during breathing and typically indicates narrowed or obstructed airways. However, several hours later, the wheezing is no longer heard. This change in the client’s condition requires immediate attention and action from the nurse.

The Nurse’s Next Action: Continuous Monitoring

When the wheezing initially resolves, the nurse’s immediate action should be continuous and vigilant monitoring of the client’s respiratory status. While the cessation of wheezing might seem like an improvement, it can also be indicative of a critical development.

Here are the steps the nurse should take:

  1. Frequent Respiratory Assessments: Assess the client’s respiratory rate, depth, and effort regularly. Note any signs of increased work of breathing, such as retractions (visible sinking of the chest or neck muscles during inspiration).
  2. Auscultation: Continue to auscultate lung sounds to detect any changes, such as the reappearance of wheezing or the development of new abnormal sounds, which could signal worsening respiratory distress.
  3. Monitor Oxygen Saturation: Use pulse oximetry to monitor the client’s oxygen saturation levels. A decrease in oxygen saturation below the target range is a concerning sign and should prompt immediate intervention.
  4. Assess for Other Signs of Respiratory Distress: Look for signs such as increased respiratory distress, cyanosis (bluish discoloration of the skin or mucous membranes), altered mental status, or restlessness. These can indicate inadequate oxygenation.

Collaborative Communication

If there are any concerning changes in the client’s respiratory status or if the client’s condition deteriorates, the nurse should promptly communicate with the healthcare team. Collaboration with physicians, respiratory therapists, and other specialists may be necessary to determine the appropriate interventions.

Potential Interventions

The nurse’s next actions will depend on the client’s condition and the underlying cause of the respiratory distress. Possible interventions could include:

  1. Repositioning: Ensure the client is in a comfortable and optimal position for breathing. Sometimes, a change in positioning can help relieve respiratory distress.
  2. Administering Oxygen: If the client’s oxygen saturation drops or if they show signs of hypoxia, oxygen therapy may be necessary. Administer oxygen via a mask or nasal cannula as prescribed.
  3. Nebulized Medications: If bronchospasm is suspected as the cause of wheezing, nebulized bronchodilator medications may be administered.
  4. Airway Management: In severe cases of airway compromise, the healthcare team may need to secure the client’s airway through intubation or other advanced airway interventions.


Accurate and timely documentation of the client’s respiratory assessments, interventions, and responses is essential for communication among healthcare providers and for maintaining a clear record of the client’s condition.


Assessing and managing clients with burn injuries and respiratory complications, such as wheezing, demand keen observation and timely intervention from nurses. In cases where wheezing resolves, continuous monitoring, auscultation, and prompt communication with the healthcare team are paramount. By staying vigilant and taking appropriate actions, nurses can contribute significantly to the well-being and recovery of clients with burn injuries.


Approximately 250 words

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